VA · Official form

VA Form 21-4142: Authorization to Disclose Information to the Department of Veterans Affairs

VA Form 21-4142 is the signed authorization that lets VA request your records from private doctors, hospitals, and other non-VA sources on your behalf in support of a benefit claim.

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What is VA Form 21-4142?

VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs, is a HIPAA-compliant release. By signing it, a claimant authorizes private health care providers and certain other sources to give VA records such as treatment notes, hospitalization summaries, and test results, so VA can obtain the evidence directly instead of the claimant collecting it.

The form pairs with VA Form 21-4142a, General Release for Medical Provider Information, which lists each provider's name, address, and treatment dates. The current edition is dated August 2024. The authorization is voluntary and can be revoked in writing, but without it VA may be unable to obtain private records that support the claim.

Who files VA Form 21-4142?

Veterans filing disability compensation claims supported by private medical treatment
Survivors and dependents whose claims rely on non-VA medical records
Claimants asked by VA to authorize release of records from a specific provider
Anyone who would rather have VA request private records than gather them personally

How to fill out VA Form 21-4142

Fill in your identifying information: name, Social Security number, date of birth, and VA file number if you have one.
Read the authorization language so you understand what you are allowing VA to request.
Sign and date the form. Unsigned authorizations are returned and delay the claim.
Complete VA Form 21-4142a alongside it, listing each provider, their address, and approximate treatment dates.
Submit both forms with your claim, upload them through va.gov, or mail them to the VA Claims Intake Center address in the instructions.

Quick fill VA Form 21-4142 on this page

Prefer to see the form itself while you type? Open VA Form 21-4142 in the editor to fill it on the actual pages, add a signature, and download.

These are the form's own fields, in the order they appear on the pages. Fill in what you know; anything left blank stays a fillable field in the PDF, so you can finish it in any PDF reader. Nothing you type here is sent to VA.

Page 1 32 fields

Read Instructions above. SECTION 1 - VETERAN IDENTIFICATION INFORMATION. Read Note above. 1. VETERAN'S NAME (First, Middle Initial, Last).

1. VETERAN'S NAME. Middle Initial. 1 character max.

1. VETERAN'S NAME. Last Name. 18 characters max.

2. Social Security Number. Enter first 3 digits.

2. Social Security Number. Enter middle 2 digits.

2. Social Security Number. Enter last 4 digits.

3. V. A. File Number (if applicable). Enter 9 digit file number.

4. Date of Birth. Enter 2 digit Month.

4. Date of Birth. Enter 2 digit Day.

4. Date of Birth. Enter 4 digit Year.

5. Veteran's Service Number (If applicable). Enter 9 digit service number.

6. Mailing Address (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country). Enter Number and Street. 30 characters

6. Mailing Address. Enter Apartment or Unit Number. 5 characters max.

6. Mailing Address. Enter City. 18 characters max.

6. Mailing Address. Enter State or Province. 2 characters max.

6. Mailing Address. Enter Country. 2 characters max.

6. Mailing Address. ZIP or Postal Code. Enter first 5 digits.

6. Mailing Address. ZIP or Postal Code. Enter last 4 digits.

7. TELEPHONE NUMBER (Include Area Code). Enter 3 digit area code.

7. TELEPHONE NUMBER. Enter first 3 digits of phone number.

7. TELEPHONE NUMBER. Enter last 4 digits of phone number.

7. Enter International Phone Number (If applicable).

8. I agree to receive electronic correspondence from V. A. in regards to my claim.

8. E-Mail Address (Optional). 15 characters max. Line 1 of 2.

8. E-Mail Address (Optional). 15 characters max. Line 2 of 2.

SECTION 2 - PATIENT IDENTIFICATION FOR RECORDS V. A. IS REQUESTING (If other than veteran). 9. PATIENT'S NAME (First, Middle Initial,

9. PATIENT'S NAME. Middle Initial. 1 character max.

9. PATIENT'S NAME. Last Name. 18 characters max.

10. Social Security Number. Enter first 3 digits.

10. Social Security Number. Enter middle 2 digits.

10. Social Security Number. Enter last 4 digits.

11. V. A. File Number (If applicable). Enter 9 digit file number.

Page 2 8 fields

SECTION 5 - AUTHORIZATION AND CONSENT TO RELEASE INFORMATION TO V. A. AND SIGNATURE. 12. IF MY CONSENT TO THIS INFORMATION IS LIMITED, THE

14. DATE SIGNED (REQUIRED). Enter 2 digit Month.

14. DATE SIGNED. Enter 2 digit Day.

14. DATE SIGNED. Enter 4 digit Year.

15. PRINTED NAME OF PERSON SIGNING (First, Middle Initial, Last). First Name. 12 characters max.

15. PRINTED NAME OF PERSON SIGNING. Middle Initial. 1 character max.

15. PRINTED NAME OF PERSON SIGNING. Last Name. 18 characters max.

16. RELATIONSHIP TO VETERAN / CLAIMANT (If other than self, please provide full name, title, organization, city, State, and ZIP code. All

Page 4 48 fields

Read Instructions above. SECTION 1 - VETERAN'S IDENTIFICATION INFORMATION. Read Note above. 1. VETERAN'S NAME (First, Middle Initial,

1. VETERAN'S NAME. Enter Middle Initial. 1 character max.

1. VETERAN'S NAME. Enter Last Name. 18 characters max.

2. SOCIAL SECURITY NUMBER. Enter First Three Digits.

2. SOCIAL SECURITY NUMBER. Enter Middle Two Digits.

2. SOCIAL SECURITY NUMBER. Enter Last Four Digits.

3. V. A. FILE NUMBER. Enter 9 digit file number.

4. DATE OF BIRTH. Enter 2 digit Month.

4. DATE OF BIRTH. Enter 2 digit day.

4. DATE OF BIRTH. Enter 4 digit year.

5. VETERAN'S SERVICE NUMBER (If applicable). 9 characters max.

SECTION 2 - PATIENT IDENTIFICATION FOR RECORDS V. A. IS REQUESTING (If other than veteran). 6. PATIENT'S NAME (First, Middle Initial,

6. PATIENT'S NAME. Enter Middle Initial. 1 character max.

6. PATIENT'S NAME. Enter Last Name. 18 characters max.

7. SOCIAL SECURITY NUMBER. Enter First Three Digits.

7. SOCIAL SECURITY NUMBER. Enter Middle Two Digits.

7. SOCIAL SECURITY NUMBER. Enter Last Four Digits.

8. V. A. FILE NUMBER. Enter 9 digit file number.

SECTION 3 - MEDICAL PROVIDER INFORMATION. 9. A. PROVIDER OR FACILITY NAME.

9. B. CONDITIONS YOU ARE BEING TREATED FOR.

9. C. DATE(S) OF TREATMENT. (Include the time period for the treatment by the provider listed in Item 9. A.). FROM DATE. Enter 2 digit

9. C. DATE(S) OF TREATMENT. FROM DATE. Enter 2 digit day.

9. C. DATE(S) OF TREATMENT. FROM DATE. Enter 4 digit year.

9. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit Month.

9. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit day.

9. C. DATE(S) OF TREATMENT. TO DATE. Enter 4 digit year.

9. D. PROVIDER / FACILITY STREET ADDRESS (Number and street, P.O. or rural route). Number and Street. 30 characters max.

9. D. PROVIDER / FACILITY STREET ADDRESS. Apartment or Unit Number. 5 characters max.

9. D. PROVIDER / FACILITY STREET ADDRESS. City. 18 characters max.

9. D. PROVIDER / FACILITY STREET ADDRESS. State or Province. 2 characters max.

9. D. PROVIDER / FACILITY STREET ADDRESS. Country. 2 characters max.

9. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter first 5 digits.

9. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter last 4 digits.

10. A. PROVIDER OR FACILITY NAME.

10. B. CONDITIONS YOU ARE BEING TREATED FOR.

10. C. DATE(S) OF TREATMENT. (Include the time period for the treatment by the provider listed in Item 10. A.). FROM DATE. Enter 2 digit

10. C. DATE(S) OF TREATMENT. FROM DATE. Enter 2 digit day.

10. C. DATE(S) OF TREATMENT. FROM DATE. Enter 4 digit year.

10. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit Month.

10. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit day.

10. C. DATE(S) OF TREATMENT. TO DATE. Enter 4 digit year.

10. D. PROVIDER / FACILITY STREET ADDRESS (Number and street, P.O. or rural route). Number and Street. 30 characters max.

10. D. PROVIDER / FACILITY STREET ADDRESS. Apartment or Unit Number. 5 characters max.

10. D. PROVIDER / FACILITY STREET ADDRESS. City. 18 characters max.

10. D. PROVIDER / FACILITY STREET ADDRESS. State or Province. 2 characters max.

10. D. PROVIDER / FACILITY STREET ADDRESS. Country. 2 characters max.

10. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter first 5 digits.

10. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter last 4 digits.

Page 5 45 fields

11. A. PROVIDER OR FACILITY NAME.

11. B. CONDITIONS YOU ARE BEING TREATED FOR.

11. C. DATE(S) OF TREATMENT. (Include the time period for the treatment by the provider listed in Item 11. A.). FROM DATE. Enter 2 digit

11. C. DATE(S) OF TREATMENT. FROM DATE. Enter 2 digit day.

11. C. DATE(S) OF TREATMENT. FROM DATE. Enter 4 digit year.

11. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit Month.

11. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit day.

11. C. DATE(S) OF TREATMENT. TO DATE. Enter 4 digit year.

11. D. PROVIDER / FACILITY STREET ADDRESS (Number and street, P.O. or rural route). Number and Street. 30 characters max.

11. D. PROVIDER / FACILITY STREET ADDRESS. Apartment or Unit Number. 5 characters max.

11. D. PROVIDER / FACILITY STREET ADDRESS. City. 18 characters max.

11. D. PROVIDER / FACILITY STREET ADDRESS. State or Province. 2 characters max.

11. D. PROVIDER / FACILITY STREET ADDRESS. Country. 2 characters max.

11. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter first 5 digits.

11. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter last 4 digits.

12. A. PROVIDER OR FACILITY NAME.

12. B. CONDITIONS YOU ARE BEING TREATED FOR.

12. C. DATE(S) OF TREATMENT. (Include the time period for the treatment by the provider listed in Item 12. A.). FROM DATE. Enter 2 digit

12. C. DATE(S) OF TREATMENT. FROM DATE. Enter 2 digit day.

12. C. DATE(S) OF TREATMENT. FROM DATE. Enter 4 digit year.

12. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit Month.

12. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit day.

12. C. DATE(S) OF TREATMENT. TO DATE. Enter 4 digit year.

12. D. PROVIDER / FACILITY STREET ADDRESS (Number and street, P.O. or rural route). Number and Street. 30 characters max.

12. D. PROVIDER / FACILITY STREET ADDRESS. Apartment or Unit Number. 5 characters max.

12. D. PROVIDER / FACILITY STREET ADDRESS. City. 18 characters max.

12. D. PROVIDER / FACILITY STREET ADDRESS. State or Province. 2 characters max.

12. D. PROVIDER / FACILITY STREET ADDRESS. Country. 2 characters max.

12. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter first 5 digits.

12. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter last 4 digits.

13. A. PROVIDER OR FACILITY NAME.

13. B. CONDITIONS YOU ARE BEING TREATED FOR.

13. C. DATE(S) OF TREATMENT. (Include the time period for the treatment by the provider listed in Item 13. A.). FROM DATE. Enter 2 digit

13. C. DATE(S) OF TREATMENT. FROM DATE. Enter 2 digit day.

13. C. DATE(S) OF TREATMENT. FROM DATE. Enter 4 digit year.

13. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit Month.

13. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit day.

13. C. DATE(S) OF TREATMENT. TO DATE. Enter 4 digit year.

13. D. PROVIDER / FACILITY STREET ADDRESS (Number and street, P.O. or rural route). Number and Street. 30 characters max.

13. D. PROVIDER / FACILITY STREET ADDRESS. Apartment or Unit Number. 5 characters max.

13. D. PROVIDER / FACILITY STREET ADDRESS. City. 18 characters max.

13. D. PROVIDER / FACILITY STREET ADDRESS. State or Province. 2 characters max.

13. D. PROVIDER / FACILITY STREET ADDRESS. Country. 2 characters max.

13. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter first 5 digits.

13. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter last 4 digits.

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Frequently asked questions

Do I need both VA Form 21-4142 and 21-4142a?

Yes, in most cases. The 21-4142 is your signed legal authorization; the 21-4142a tells VA which providers to contact and for what dates. VA generally needs both to actually request your private records.

Does this form cover VA medical records too?

No authorization is needed for VA's own treatment records; VA can pull those internally. This form covers non-VA sources such as private doctors, hospitals, and clinics.

Can I cancel the authorization later?

Yes. You can revoke it in writing at any time, though the revocation does not undo disclosures VA already received while the authorization was valid.

VA Form 21-4142: Authorization to Disclose Information to the Department of Veterans Affairs

What is VA Form 21-4142?

Who files VA Form 21-4142?

How to fill out VA Form 21-4142

Quick fill VA Form 21-4142 on this page

Frequently asked questions

Related forms

VA Form 21-4142a: General Release for Medical Provider Information to the Department of Veterans Affairs

VA Form 21-526EZ, Application for Disability Compensation

VA Form 10-5345: Request for and Authorization to Release Health Information